Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.

Sunday, February 05, 2017

We frequently discuss the anechoic effect, the failure of cases illustrating problems with concentration and abuse of power, unethical and corrupt behavior, and faulty leadership and governance in health care to generate much public discussion, much less outrage. In particular, physicians and other health care professionals seem very reluctant to discuss such cases, perhaps fearing disapproval or retaliation by colleagues or bosses. But they times they are a changin'.

Dr Delos (Toby) Cosgrove had been accused of multiple conflicts of interest the first decade of the century. These charges seemingly generated no local expressions of concern. Yet in recent days, a considerable number of physicians, nurses, house-staff and students at the prestigious Cleveland Clinic have loudly and publicly challenged the actions of their CEO, and these challenges have received national attention.

Cleveland Clinic CEO Dr Delos (Toby) Cosgrove first graced the pages of Health Care Renewal in 2005. The story back then was a complicated one of conflicts of interest.

Dr Cosgrove had been a well-paid general partner of the Clinic's private venture capital fund, Foundation Medical Partners (FMP), while he was Chairman of Cardiovascular and Thoracic Surgery. FMP invested in a device company called AtriCure, and Dr Cosgrove became a director of the company. Dr Cosgrove used the company's devices in his work, and wrote a paper about the device which did not disclose his conflicts of interest in the company. The conflicts of interest committee at the Clinic began looking into these financial relationships. Soon after, Dr Cosgrove stepped down from his directorship at Atricure and his role at FMP. Then Dr Cosgrove, who by then was CEO, announced that prominent cardiologist Dr Eric Topol, who was on the committee investigating his conflict of interest, was leaving his post as chief academic officer of the Foundation and provost of the medical school, supposedly for "streamlining" purposes, raising questions that Dr Topol was punished for being a whistle-blower.

Questions about Dr Cosgrove's conflicts of interest did not end there, per a post written in 2007. At that time, allegations were made that Dr Cosgrove's conflicts of interest received preferential treatment at the Clinic. In 2008, the Cleveland Clinic revealed that Dr Cosgrove had other conflicts of interest, including royalty payments from several biotechnology and device companies (see this post). In 2010, AtriCure, the company with which Dr Cosgrove had been so prominently involved, settled charges that it marketed a device for unapproved indications (see this post).

Those old stories with their suggestions of scandals did not apparently derail Dr Cosgrove's continued success at the Cleveland Clinic. By 2015, per Cleveland.com, Dr Cosgrove was the best compensated non-profit CEO in the Cleveland area, receiving $4.8 million.

Dr Cosgrove had become so prominent in 2016 that again per Cleveland.com:

President-elect Donald Trump tapped Cleveland Clinic CEO Dr. Toby Cosgrove to join a newly established panel of 16 business leaders that will advise Trump on how government affects job and economic growth, according to the Cleveland Clinic.

The President's Strategic and Policy Forum will offer non-partisan advice to the president as he assumes office, according to a Trump team news release obtained through the Clinic.

'I am truly honored and privileged to take part in President-elect Donald Trump's Strategic and Policy Forum designed to grow and strengthen the United States' economy,' Cosgrove said in a statement Friday. 'I applaud his efforts to bring together leaders across industries to gain insight that will assist the new President in making important decisions that will impact every American. I am deeply committed and take this role very seriously.

Note that nearly all the members of the Forum were CEOs of huge for-profit corporations, the Forum's purview was economic, not on health care, medicine, or biomedical research, and Dr Cosgrove acknowledged all that, but was pleased to serve. This suggests that despite his medical degree, Dr Cosgrove saw himself more of a big business leader than a physician or academic leader.

This, along with his huge compensation package, puts him into the center of the pack of managerialist leaders of health care organizations, despite his medical degree. We have frequently posted about what we have called generic management, the manager's coup d'etat, and mission-hostile management.
Managerialism wraps these concepts up into a single package. The idea
is that all organizations, including health care organizations, ought to
be run people with generic management training and background, not
necessarily by people with specific backgrounds or training in the
organizations' areas of operation. Thus, for example, hospitals ought
to be run by MBAs, not doctors, nurses, or public health experts.
Furthermore, all organizations ought to be run according to the same
basic principles of business management. These principles in turn ought
to be based on current neoliberal dogma,
with the prime directive that short-term revenue is the primary goal.

The Cleveland Clinic and the Ban on Muslim Immigration

A House-Staff Physician Deported Due to Trump's Travel Ban

Dr Cosgrove's role in the Trump administration did not prevent the Clinic from getting caught up in President Trump's executive order that stopped immigrants from seven predominantly Muslim countries from entering the US. Per Cleveland.com (Jan 28, 2017),

An internal medicine resident at the Cleveland Clinic who is a citizen of Sudan said Saturday that she was detained in New York when she was trying to return to Ohio after a trip to Saudi Arabia and was put on a plane back to the Middle East.

Dr. Suha Abushamma, who has worked at the Clinic since July on a work visa, left the U.S. one day after an executive order issued by President Donald Trump. The executive order included a crackdown on immigration from refugees and citizens of seven majority-Muslim countries.

Abushamma, 26, of Cleveland Heights, lived in Saudi Arabia before being hired at the Clinic. She is a Muslim woman and a citizen of Sudan.

Cleveland Clinic Leadership Barely Responds

The official Cleveland Clinic reaction to the deportation of one of its house-staff was muted, and certainly did not directly challenge the executive order. Becker's Hospital review quoted its statement,

Recent immigration action taken by the White House has caused a great deal of uncertainty and has impacted some of our employees who are traveling overseas. We deeply care about all of our employees and are fully committed to the safe return of those who have been affected by this action.

Health Care Professionals and Trainees Learn to Resist

Cleveland Clinic health care professionals and trainees were not satisfied with that bland official response, especially when they were reminded of the Clinic's ties to the Trump administration. Per Cleveland.com, (Jan 30, 2017),

The Cleveland Clinic is receiving unwelcome attention for moving
forward with plans to hold a fundraiser next month at President Donald
Trump's flagship resort.

A Cleveland Clinic resident joined several faculty at other medical schools in calls on the Clinic to cancel the fundraiser.

So CEO Cosgrove serves on President Trump's business council, while CEO Cosgrove's Cleveland Clinic will personally profit President Trump by paying for a fundraiser at the resort he owns, while the Clinic fails to challenge the deportation of one of its own trainees at the behest of President Trump's executive order. The web of conflicts of interest is dizzying to behold.

Resistance Grows

On Feb 2, 2017, StatNews reported the protests at the Clinic were becoming more widespread:

Hundreds of medical students and doctors have signed an open letter
urging Cleveland Clinic to cancel a February fundraiser at the Florida
resort owned by President Trump, after his executive order on
immigration blocked one of the clinic’s doctors from reentering the US.

The letter, with more than 400 signatures, also
calls on the clinic to publicly condemn Trump’s order, protect the
clinic’s employees from deportation, and reaffirm its commitment to
diversity. Dozens of the signers are medical students at Case Western
Reserve University, which operates the Lerner College of Medicine in
partnership with the clinic.

'Your willingness to hold your fundraiser at a
Trump resort is an unconscionable prioritization of profit over people,'
the letter states. 'It is impossible for the Cleveland Clinic to
reconcile supporting its employees and patients while simultaneously
financially and publicly aiding an individual who directly harms them.'

Note that this letter suggests that CEO Cosgrove puts the Clinic's, and possibly his own personal business interests ahead of the interests of its health care professionals and trainees, their values, and/or their patients. This suggests that CEO Cosgrove is exerting mission-hostile management, perhaps due to his conflicts of interest. Managerialist leaders frequently seem to lead in ways that undermine the missions of their organizations. Yet again, up to now there has been very little organized protest of managerialist leadership, mission hostile leadership, conflicted leadership, etc of big health care organizations by health care professionals.

Not only did the Clinic refuse to cancel the fundraiser, but CEO Cosgrove got into a tussle with a reporter over the dispute,

The controversy led to a dustup between Cosgrove and New Yorker writer
Kathryn Schulz, who tweeted Cosgrove’s office number to her followers
and urged them to call him directly to voice their concerns about the
Mar-a-Lago event.

Schulz wrote Cosgrove a personal email criticizing Trump’s order and
warning him that the clinic will 'lose the respect of millions of
Americans' if it proceeds with the event. Schulz’s email, obtained by
STAT, referenced that her late father received excellent care from
doctors there, some of it delivered by a Syrian immigrant. 'Please don’t
dishonor him or your heretofore outstanding reputation,' the email
said.

Schulz later tweeted that she received an 'irate & dismissive' reply from Cosgrove. She has also signed the petition.

Cosgrove’s reply, also obtained by STAT says, in part: 'I also
appreciate you expressing your concern about our forthcoming gala at
Mar-a-Lago. I do not however appreciate you having your colleagues
inundate my office with emails and phone calls which is very disruptive
to our main activity of putting patient’s first. I would ask you to
please refrain from this activity because it is counter-productive to
that which we are all trying to accomplish.'

Note that in this exchange CEO Cosgrove alluded to the fundamental mission of his organization to put patients first, but did not explain how his relationships with the Trump administration, and his failure to challenge the travel ban and its direct effect on at least one of his house-staff furthered that mission.

As if to underline Dr Cosgrove's continued support of the Trump administration, on Feb 2, 2017, Cleveland.com reported that the CEO would be attending the President's Strategic and Policy Forum as planned. However, Cleveland Clinic physicians were not mollified. On that same day, Cleveland.com also reported,

About two dozen Cleveland Clinic doctors gathered this morning to show their support for colleague Dr. Suha Abushamma, a resident who was detained and unable to return to the United States over the weekend due to President Trump's executive order on immigration.

Holding photos of Abushamma and signs reading '#BringSuhaBack,' the group stood silently in the Clinic's Miller Pavilion at 7 a.m., only speaking to say the pledge of allegiance.

By the next day, the case was being reported in the Washington Post, as the protest continued to grow. The Post article stated that doctors, nurses and student had signed the letter, which by then at 1141 signatures.

At the time I write this, Dr Abushamma had not returned to the US, but had filed a lawsuit challenging the travel ban.

Summary

Over the last 30 years, many health care organizations have been taken over by managerialist leadership, often by generic managers. Such leadership may have conflicts of interest, and may put their organizations' revenues, and sometimes their personal fortunes, ahead of patients' interest and health care professionals' values. Yet while Health Care Renewal has repeatedly documented managerialism, generic management, mission-hostile management, conflicts of interest, and various threats to professional values, there have been little organized resistance by health care professionals to these aspects of health care dysfunction.

President Trump, however, has unwittingly inspired lots of resistance. It seems that health care professionals now may be learning to resist their own leaders when resistance is due.

So maybe more people will be listening as I repeat this mantra....

I now believe that the most important cause of US health care
dysfunction, and likely of global health care dysfunction, are the
problems in leadership and governance we have often summarized
(leadership that is ill-informed, ignorant or hostile to the health care mission and professional values, incompetent, self-interested, conflicted or outright criminal or corrupt,
and governance that lacks accountability, transparency, honesty, and
ethics.) In turn, it appears that these problems have been generated by
the twin plagues of managerialism (generic management, the manager's coup d'etat) and neoliberalism
(market fundamentalism, economism) as applied to health care. It may
be the many of the larger problems in US and global society also can be
traced back to these sources.

We now see our problems in health care as part of a much larger whole,
which partly explains why efforts to address specific health care
problems country by country have been near futile. We are up against
something much larger than what we thought when we started Health Care Renewal in 2005. But at least we should now be able join our efforts to those in other countries and in other sectors.

True health care reform would restore health care leadership that
understands health care and medicine, upholds the health care mission,
is accountable for its actions, and is transparent, ethical and honest.

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